<form action="<?php echo $baseUrl ?>/payment/buybidpack" method="post">
        	<input type="hidden" value="<?php echo $bidPackId;?>" name="BillingInfo[bidPackId]" />
	        <div class="info-box">
	        	<div class="payment-method">
	            	<p class="title">Select Payment method</P>
	                <ul>
	                <li><input type="radio" name="BillingInfo[payby]" value="<?php echo PayPal::API_NAME;?>" /><img alt="" src="<?php echo $baseUrl ?>/images/paypal.png" /></li>
	                <li><input type="radio" name="BillingInfo[payby]" value="<?php echo AuthorizeNet::API_NAME;?>" checked /><img alt="" src="<?php echo $baseUrl ?>/images/bank-card.png" /></li>
	                </ul>
	            </div>
	            <div class="billing-address">
	            	<p class="title">Billing Address</P>
	                <ul>
	                <li><label>First Name</label><input type="text" name="BillingInfo[first_name]" /></li>
	                <li><label>Last Name</label><input type="text" name="BillingInfo[last_name]" /></li>
	                <li><label>Address</label><input type="text" name="BillingInfo[address1]" /></li> 
	                <li><label>City</label><input type="text" name="BillingInfo[first_name]" /></li>
	                <li><label>State</label>
	                	<select name="BillingInfo[country]">
	                		<?php foreach($states as $state){?>
	                		<option value="<?php echo $state['key']?>"><?php echo $state['name']?></option>
	                		<?php }?>
	                	</select>
	                </li>
	                <li><label>Country</label>
	                	<select name="BillingInfo[country]">
	                		<?php foreach($countrys as $country){?>
	                		<option value="<?php echo $country['key']?>"><?php echo $country['name']?></option>
	                		<?php }?>
	                	</select>
	                </li>
	                
	                <li><label>Zip</label><input type="text" name="BillingInfo[first_name]" /></li>
	                </ul>
	            </div>
	            <div class="clear"></div>
	            <div class="billing-address patment-details">
	            	<p class="title">Payment Details</P>
	                <ul>
	                <li><label>Card Number:</label><input type="text"  name="BillingInfo[card]"/></li>
	                <li><label>Exp.date</label>
		                <select name="BillingInfo[month]">
		                	<?php foreach($ExpirationDateMonth as $key => $val):?>
								<option value="<?php echo $key;?>" <?php if(date('m')== $key ) echo 'selected';?> ><?php echo $val;?></option>
							<?php endforeach;?>
		                </select>
	                	<select name="BillingInfo[year]">
	                		<?php foreach ($ExpirationDateYear as  $key => $val):?>
								<option value="<?php echo $val;?>" <?php if( date('Y')  == $val ) echo 'selected';?> ><?php echo $val;?></option>
							<?php endforeach;?>
	                	</select>
	                </li>
	                <li><label>CVV</label><input class="cvv" type="text" name="BillingInfo[cvv]" /><span>(where do I get these 3 digits)</span></li>
	                
	                </ul>
	            </div>
	             <?php echo CHtml::imageButton($baseUrl."/images/ready-winning-btn.png",
						array('class' => 'ready-winning-btn'))?>
	        </div>
	     </form>